1	Medical Records for Nonrodents May 2002
2	Introduction This training module is designed to introduce investigative staff to our record keeping system It is essential that observations, manipulations and treatments be recorded on the medical record in a timely way The system is designed to comply with all provisions of the Animal Welfare Act
3	Nonrodent Species
4	Nonrodents Covered Rabbits Medical record is established whenever a rabbit has medical and/or surgical intervention or a medical problem is noted.
5	Post procedural Care Three different forms are used to document post procedural care Anesthesia Recovery Form: Monitors the animals condition as the anesthetic wears off Postoperative Evaluation Form: Monitors the first few days following a procedure until the animal has stabilized Research Animal Clinical Record Form: Monitors continued treatment of animals and documents all treatments and procedures
6	Anesthesia Recovery Form Monitoring is provided con-tinuously until extubation Then, every 30 minutes until the animal is able to rest upright without help (sternal recum-bency)
7	Anesthesia Recovery Form Monitoring is provided continuously until extubation Then, every 30 minutes until the animal is sternal
8	Postoperative Evaluation Form Animals must be observed daily until sutures are removed and animal has stabilized Observations should be documented on the post operative evaluation form Use SOAP format Subjective Objective Assessment Plan
9	"Postoperative Evaluation Form" Postoperative Evaluation Form Record all observa-tions Records should enable the clinical staff to make a quick assessment of the postoperative progress of the animal
10	“SOAP”ING RECORDS All observations and treatments must also be documented on the Research Animal Clinical Record The SOAP format should be used when making entries on the clinical record The SOAP format provides a standardized systematic way to properly document observations and treatments Incomplete documentation is interpreted by regulators as failure to provide adequate care
11	Research Animal Clinical Record Form SOAP Example Subjective: Appears painful, depressed Objective: Temp 101^oF, incision clean and intact, minimal swelling, Not eating much. Normal color, hydration Assessment: No sign of infection. Post-operative pain Plan: Give buprenorphine, tempt to eat, monitor weight, continue observation
12	Location and Filing of Medical Records Records are filed in a rolling file box in the animal housing room. The records are arranged by investigator and/or by surgery date for rabbits.
13	Daily Documentation of Observation/Treatment is Required For . . . Animals with Eliza-bethan collars or restraint jackets Animals with ban-dages Animals on daily experimental or medical treatment
14	Thank You Thank you for completing our medical records module If you have any questions, please contact us You may document this training by taking the Nonrodent Medical Record Test